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Fetal heart monitoring in labour: intermittent auscultation, CTG in general terms and intrauterine resuscitation

  • Assessment

In a healthy labour the fetal heart is checked at set times with a Doppler or Pinard. If the rate is abnormal, turn the woman on her side and call.

Updated

What it is

Listening to the fetal heart is the main way to check the baby's wellbeing during labour. WHO recommends intermittent auscultation with a handheld Doppler or a Pinard stethoscope for healthy women, and does not recommend routine cardiotocography (CTG) on admission or continuous CTG in a normal spontaneous labour. CTG is used for women with risk factors, following the institutional protocol. The nurse counts the rate, notes decelerations and the colour of the amniotic fluid, and starts the first measures when the heart rate is abnormal.

Reference values

  • Labour Care Guide: a baseline from 110 to 159 beats per minute, with no late decelerations, is outside the alert range.
  • Early decelerations happen with the contraction and recover with it; CLAP explains them as a vagal response to head compression, usually without fetal hypoxia.
  • Late decelerations start after the contraction peak and recover after it ends; they suggest fetal hypoxia.
  • Variable decelerations change in shape and timing and suggest cord compression; CLAP treats them as an alarm, more so when they last over 40 seconds.
  • WHO manual: a very slow rate without contractions, or persisting after them, suggests fetal distress; a fast fetal rate without a fast maternal rate is also a warning sign.

What you need

  • A handheld Doppler or a Pinard fetal stethoscope.
  • A watch with a second hand.
  • The partograph or Labour Care Guide.
  • A CTG monitor when the protocol indicates it.

How to measure it (and why)

  1. Explain what you will do and ask for consent — the woman takes part in her care.
  2. Help her into a position other than flat on her back — the Labour Care Guide treats the supine position as an alert.
  3. Find the fetal back by palpation and place the device over the fetal shoulder area, as CLAP describes — the heartbeat is usually heard there.
  4. Feel the mother's radial pulse while listening — so the two rates are not confused.
  5. Listen during a contraction and up to 30 seconds after it, for at least one minute — decelerations show up during and after.
  6. Count the baseline between contractions and note any deceleration (none, early, late or variable) — the type changes what you do.
  7. Note the state of the membranes and the colour of the fluid — thick meconium or blood-stained fluid is an alert.
  8. Record the values at once on the partograph or guide — a late record cannot trigger action.
  9. If abnormal, turn her to the left, stop oxytocin, check her blood pressure and listen for longer — then call.

How to read it

  • A rate that is normal again after turning the woman and correcting the cause is still recorded and reported.
  • A fast fetal rate may come from maternal fever, some drugs or infection of the membranes; look for the maternal cause (WHO manual).
  • Membranes just ruptured plus a sudden change in the fetal heart: think of cord prolapse (see obstetric emergencies).
  • CTG reading (baseline, variability, accelerations, decelerations) follows the institutional protocol and is interpreted with the doctor.

Next step: when to call for help

  • Call the senior midwife or doctor at once for: a baseline below 110 or 160 and above, late decelerations, a single prolonged deceleration, or thick meconium or blood-stained fluid.
  • Call at once if the fetal heart cannot be found.
  • Call at once if the cord is seen or felt in the vagina.
  • If the rate stays abnormal over three contractions, the doctor examines the woman and decides how the baby will be born (WHO manual).

Test yourself

Think of the answer, then tap the question to see it.

For how long and when is the fetal heart heard in intermittent auscultation?

At least one full minute, during a contraction and for at least 30 seconds after it.

Why feel the mother's pulse while listening to the fetal heart?

So her heartbeat is not counted as the baby's.

Which type of deceleration suggests fetal hypoxia?

Late decelerations, which start after the contraction peak and recover after it ends.

What are the first nursing measures for an abnormal fetal heart rate?

Turn the woman on her left side, stop oxytocin if it is running, check her blood pressure and call the senior midwife or doctor.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: WHO Labour Care Guide: user's manual (World Health Organization, 2020); Salud sexual y reproductiva: guías para el continuo de atención de la mujer y el recién nacido focalizadas en APS, 3.ª ed. (CLAP/SMR 1577) (Organización Panamericana de la Salud, CLAP/SMR, 2011); Managing complications in pregnancy and childbirth: a guide for midwives and doctors, 2nd ed. (World Health Organization, 2017); Resolución 3280 de 2018: lineamientos técnicos y operativos de la Ruta de Promoción y Mantenimiento de la Salud y de la Ruta Materno Perinatal (Ministerio de Salud y Protección Social de Colombia, 2018).

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